title: A pilot survey of decisions by acute medicine staff after thunderclap headache.
abstract: OBJECTIVE
  Traditionally, neurologically pristine patients with a thunderclap headache are investigated with a non-contrast computed tomography (CT) brain scan, which if negative is followed by a lumbar puncture (LP) to exclude important secondary causes, particularly subarachnoid haemorrhage (SAH). However, misdiagnosis of such patients is still a cause of significant human and financial cost and a regular reason for medical litigation. This study explores the approach of emergency medicine and acute medicine clinicians to the investigation of a patient with thunderclap headache.
  
  
  METHODS
  Clinicians were invited to complete an online survey based on a clinical vignette of a 45-year-old man presenting with a thunderclap headache who had a pristine neurological examination.
  
  
  RESULTS
  A total of 160 clinicians responded. The majority (89%) elected to perform a non-contrast CT brain as their first investigation, though five clinicians discharged the patient without investigation. If the CT was negative, only 84% would then proceed to LP, but 20% would undertake this investigation before 12 hours from headache onset.
  
  
  CONCLUSIONS
  Most clinicians investigate neurologically intact patients with thunderclap headache following a CT/LP strategy, but deviations from recommended practice are common.
authors.affiliation: B Dobb, Acute Medicine Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK. bendobb@nhs.net.
authors.forename: B
authors.initials: B
authors.lastname: Dobb
authors.forename: J
authors.initials: J
authors.lastname: Cooper
mesh_terms: D001921:Brain / Q000000981:diagnostic imaging; D002555:Cerebrospinal Fluid / Q000382:microbiology / Q000821:virology; D003625:Data Collection; D003937:Diagnosis, Differential; D051270:Headache Disorders, Primary / Q000000981:diagnostic imaging / Q000209:etiology*; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000175:diagnosis; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D013129:Spinal Puncture; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000175:diagnosis*; D014057:Tomography, X-Ray Computed
keywords: Headache; intracranial aneurysm; subarachnoid haemorrhage; survey; thunderclap headache